HomeMy WebLinkAboutZ-9471FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPA31TMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No..Z9~l .....
Date ..... March .... 23 ........... , lg..7.9
THIS CERTIFIES that the building located at . .2~ 02 .Wes.tpheLt, a. Ri, .... ~
Map No... x~,i. xxx · ' Block No.. 'xxxxxx Lot No ...... ~ .................
conforms substantially to the ' L . PRIOR
~ 'Al~ri-%' 23 19'57' pursuantt°which~~I°.0cCUPANCY
........... ' 'Z9471 '
dated ..... l~lar0tl .... 23 ...... , 19.79' was issued, and conforms'to all of the require-
ments of the applicable provisions of the law. The occupancy for. which this certificate is
issued is ........... Pr£v. ate..One. Eamlly. I~elling .............................
The certificate is issued to .............. Ruth..V....Has~ ......... .~ ..................
(owner, ~
of the aforesaid building.
Suffolk County Department of Health Approval ........ P~.e-Existlng .............
UNDERWRITERS CERTIFICATE No ................. I~e.-Exls.tiLrlg. '
HOUSE NUMBER '-'2102 ...... Street ............. Westph~ia' 'Rd;~' ...........
..................................................~~~Matt ck;'-Ne~ 'York ......
County Tax Number
1000-11;~07-011
FORM NO. 6
TOWN OF SOUTHOLD
, Building Deportment
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in DUPLICATE to the Building
Inspector with the following; for new buildings or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and
unusual natural or topographic features.
2. Final approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and
installations, a certificate of Code compliance from the Architect or Engineer responsible for
the building.
5. Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey.of property showing all property lines, streets, buildings and unusual natural
or topographic features.
2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in-
formation required to prepare a certificate.
C. Fees: 1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling or land use $5.00
3. Copy of certificate of occupancy $1.00
New Building ................ Addition ................ Old or Pre-existing Building ..... ..X. ........ Vacant Land ..............
Location Of Property ...1~.~..g..h..t.T..~.~T..~..a..~....~.~..~.?.~.?"h...~...~:.a...~.~./.~..~...~..t:~?..~...~...~..~.~.~ .........................
Owner Or Owners Of Property ~.R.~.~.h.~`a..~..~?.....~...~..~.m.?...t..e.~.~.a..~n..~.~.~.R..~..`t:.h..~.V.~:~.H...a..a..~. .................................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No ..................... Date Of Permit .................... Applicant ..................................................................
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Temporary Certificate ........................................ FinaJ Certificate ........... ..X. ............................
Fee Submitted $ ..5......0..0.. .........................
Const ruction on above descri bed building and p/e~' ~).eets/al/~plic~_ e/a/eries and regulations.
Applicant ........................ ;~ .................................
Sworn to before me this .~.. ~__ ,.~
....2...];.?...~.... day of ...... .~...a..~..0...~..~.....]:...9.7..9. ............ (stamp or seal
Nota Public ......... ........... County
~'~"~ ~) ~,'~. --/,..,x ) .L.,.,,/, -- Notary Public, State Of New York
No. 52-4635190 Suffolk Caunt~
~ommission Expires March 30,
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